Comparison between the Laparoscopic Appendectomy and Open Appendectomy for Child

Appendicitis is a global disease that continues to have high levels of prevalence in the West
and is rapidly growing in the era of increased industrialized world. Due to the severity of this
condition, many scholars together with the practitioners in the medical field have attempted to
explore the conditions and appropriate remedies (Ferris et al., 2017). Appendicitis is a condition
where the appendix gets swollen, inflamed and filled with pus (Ferris et al., 2017). This is a
lethal condition because if the appendix ruptures, it poses a risk to the patient of suffering from
severe infections that can be fatal if not treated. Appendicitis condition is common among the
people in America but is more prevalent among the Children. According to the statistics captured
by the Glass & Rangel (2016), about 80000 children are affected by this condition annually in
the United States. Additionally, children are affected more severely due to the diagnostic
challenges that they face and late complications. Despite the availability of the diagnostic
imaging, the common surgical emergencies that occur affect children and hence many
practitioners in the medical field consider them as a special group in the population.
The causes of the appendicitis are related to the obstruction of the appendix, blow flow
obstruction, and infections among others. The disease is characterized by a steady sudden pain
around the belly or the right part of the belly, low fever, vomiting, nausea, and diarrhoea
(Reddan et al., 2016). Due to the severe pain that is associated with appendicitis condition, it is
necessary to take a remedial treatment, which is surgical in nature. There are two surgical
treatment methods for this condition: the traditional based appendicitis open appendectomy (OA)
and laparoscopic appendectomy (LA). Open appendectomy is considered the traditional
approach, which was consolidated by MCBurney into a 5 cm incision at the lateral border of the

right rectus muscle between the umbilicus and the right anterior-superior iliac spine. After
making the incision, the appendix and the caecum are brought of the peritoneal cavity where the
mesoappendix is ligated and the appendicular base is divided to leave a stump (Switzer, Gill and
Karmali, 2012). However, this method of surgical treatment leaves a large wound due to the
incision and hence medical practitioners and researchers started to study the impact of this on
patients.
In the advent of the new method, LP, analysts found that this approach could be much better
on patient recovery compared to the OP approach. In the year 2009, a study conducted in
Germany found that nearly half of the patients who underwent the OP surgical treatment, which
is an equivalent 46%. Moreover, a study conducted later showed that OP still accounts for a large
proportion and recognition (White et al., 2019). OP was maintained up until the year 1983, when
Kurt Semm introduced the first successful laparoscopic appendectomy. LP is performed by
placing a 10mm camera orifice at the umbilicus and a 5mm camera orifice in the right iliac fossa
and the right hypochondriac quadrant at three ports. According to the camera, operated by
Babcock clamp, endoscopic stapling assistance, remove the appendix from the abdominal cavity
(Switzer, Gill and Karmali, 2012).
Since then, laparoscopic appendectomy has become very more popular. There has been vast
evidence that showed that LP has many advantages compared to the traditional approach. Some
of the advantages that are associated with LP include faster recovery, better pain management
and control, and lesser levels of infections (Low et al., 2019). Despite the problem of
appendicitis getting more prevalent in society, health practitioners in this sector is still struggling
with the decision making process. This is majorly contributed by the lack of a clear comparison
between the OP and LP as surgical treatment for the highly prevalent problem of acute

appendicitis. Indeed, there are no conclusive studies that justify the choice between Open
appendectomy and Laparoscopic Appendectomy with great sense of finality. Some scholars have
argued that OP is also advantageous since it has short operation time, wound infection rate is
low, but it has a longer hospital stay with low postoperative recovery. For instance, seven of the
eight meta-analyses showed that LP reduced hospital stay from 0.16 days to 1.13 days.
Meanwhile, there is a systematic review including more than 100,000 cases of appendectomy in
children, which found that LP reduced hospital stay and overall morbidity in children (Childers
et al., 2019). On the other hand, LP abdominal wall trauma is small, postoperative recovery is
fast, but the operation time is long, wound infection rate is high. As such, by comparing these
two surgeries, it is possible to make a conclusion which of the two is more advantageous. This
study seeks to make a more pronounced decision on which of the two approaches is more
advantageous.
1.2 Statement of the Problem
Appendicitis remains a common problem in the Western countries and especially among the
children yet the choice of the surgical treatment between LA and OA remains unclear and
medical practitioners are faced in the dilemma in making the choice of the two. The incidence of
appendicitis got a peak in the middle of the 20 th century where over up to 383 people a year per
100000 people was affected by the condition. In the provision of a remedial treatment for this
fatal condition, the western countries have a good control by advances in diagnostic methods,
medical management and surgery. In contrast, Asia, the Middle East, Africa and South America
and the incidence of newly industrialised countries is on the rise, rates even higher than many
western countries. The incidence of appendicitis in western countries has experienced the rise,

smooth down to the present stable, but the incidence of newly industrialized countries due to
accelerate the economic development of rising, also did not reach the peak.
Appendicitis is undoubtedly a burden that cannot be ignored in the world, especially in
countries with increasing incidence. Children are considered as special group as they are severely
affected by the surgical operations, therefore, and the provision of the recovery plan is highly
welcomed. It is necessary for newly industrialised countries to improve their health care systems,
prepare the clinical infrastructure, strengthen the regulation of diseases and control the incidence
of appendicitis in a good way. In addition to geographical factors, the incidence of appendicitis
was associated with race, gender, and seasonal variations as well (Luckmann and Davis, 1991).
In treating the condition, there are two surgical approaches for this condition: OP and LP. The
treatment total cost of two kind surgeries requires staff salaries, operating room consumables,
management cost and equipment maintenance cost (Lintula et al., 2004). Nonetheless, there is a
difference in the requirement between the two approaches but, there is no clear clinical
indication of which surgical method is more suitable for the treatment of appendicitis in children.
In addition, the two approaches, LA and OA, leads to varied outcome on the patient but there is
no clear distinction which of the two is better. This study is based on the hypothetical statement
is more suitable surgical treatment method but this has not been identified are confirmed with
confidence. This problem makes it difficult for parents in choosing the type of the surgical
operation for their children between OP and LP.
1.3 Research Questions and Objectives
The aim of this study is to conduct a comparison between the laparoscopic appendectomy
and open laparoscopic appendectomy as surgical treatment approaches to the problem of

appendicitis and make a conclusion of the most appropriate method for children hence improve
the nurses’ knowledge.
Research Questions
I. What is the difference between open appendectomy and open laparoscopic appendectomy as
surgical treatment for appendicitis?
II. Following the concept of patient-centered care, which of the two approaches is more
concerned with the patients?
III. Which of the two approaches open appendectomy and open laparoscopic appendectomy are
most appropriate for children as a treatment method of surgical treatment for appendicitis?
1.4 Rationale of the Study
This study seeks to provide information that will help patients and practitioners in making
decision on the most appropriate method of treating surgical treatment. The researcher contends
that in the health practice, having worked in children’s surgery department at Children’s Hospital
for two years in China, there industry is faced with the challenge of making the choice of the best
surgical method between the OP and LP for the treatment of the appendicitis. Many parents
choose laparoscopic surgery when choosing the type of surgery, and most doctors recommend
this procedure as well however, their choice is not driven by the absolute comparison of the two
approaches. Scholars argue that it seems that laparoscopic surgery has a high probability of
covering the treatment of appendicitis surgery while some prefer the OP due to some of the
positive attributes also. This shows that parents prefer to choose laparoscopic surgery, but there
is no clear clinical indication of which surgical method is more suitable for the treatment of
appendicitis in children. Parents choose the LP surgical procedure, postoperative treatment and
care have been highly valued clinically, the postoperative recovery time and postoperative pain

response and complications need to be closely observed. With the findings from this research,
scholars, parents, and practitioners will be able to make a profound decision between the LP and
OP. Therefore, this study contributes to the surgical operations as well as to the diagnosis and
treatment of the appendicitis with the right choice of the surgical operation.

Chapter 2: Literature Review

2.1 Appendicitis and its Prevalence
Appendicitis is among the commonest surgical emergencies and is a common cause of
abdominal pain. In the US, 250,000 cases of appendicitis are recorded every year, which
represents 1 million of patient days of admission (Danwang et al., 2018). The incidence of the
acute appendicitis decline in a steady manner since the late 1940s and the current incidences that
are reported are at 10 cases in a 100,000 people (Danwang et al., 2018). In the US appendicitis
occurs in 7% of the US population where an incidence of 1.1 cases per 1000 people in a year
(Danwang et al., 2018). In the African and Asian nations, the incidence rate is much lower due to
the dietary habits of the people inhabiting this geographic area. The lower incidence is associated
with the high intake of the dietary fibers. Danwang et al. (2018), state that appendicitis is an
acute inflammation of the appendix, and is the most frequent etiology for the acute surgical
abdominal pain among the developed countries.
Danwang et al. (2018) state that in the USA, the number of people who are undergoing
appendectomy in acute care hospitals are estimated at 300,000. While also exploring the
prevalence of appendicitis, Ferris et al (2017), noted that the incidences of appendicitis escalated
in the Western countries during the 1990s without a clear explanation but later decreased in the
mid-20 th century. On the other hand, acute appendicitis is not common outside the Western
countries during the 20 th century but is reportedly rising with the increase in the industrialization.
Understanding the global evaluation of the appendicitis in the countries that have become
heavily industrialized is necessary for the planning of the healthcare and resource utilization
towards this problem. In the western countries, appendicitis is highly associated with morbidity,
mortality, and high costs in the healthcare system. Indeed, Ferris et al (2017) notes that the life-

time risk of appendicitis in the US is 1 person per 15. In addition, one third of the appendicitis
cases are presented to the hospital with a perforated appendix, which depicts the fatality of the
condition.
Due to the high prevalence of the condition in the developed nations, the cost of
hospitalization is relatively high. For instance, the cost of appendicitis related healthcare amounts
to $3 billion per year in the United States. It is based on this prevalence that Becker, Fichtner-
Feigl & Schilling (2018) advocates for a reevaluation of the impact of the appendicitis on the
entire healthcare system across the globe. In addition, the rising incidences of the appendicitis in
the increased industrialized world indicate that there are chances of the outbreak of the
appendicitis other nations outside the Western regions. The clinical infrastructure in the newly
industrialized countries needs to be restructured to mitigate the morbidity as well as the mortality
of the appendicitis. Moreover, the contrasting of the incidences in the Western countries and the
newly industrialized countries offers a clue to the underlying environmental underpinning of the
appendicitis. By identifying the triggers of the appendicitis condition, the public policy initiative
may be instituted to modify the environmental exposures thereby preventing appendicitis. Based
on this, scholars conducted a systematic review of the population based studies to report on the
incidences of the condition across the world. The general consensus was that there was a trendy
increase of the cases of appendicitis across the developing nations with the wake of the
industrialization. Becker, Fichtner-Feigl & Schilling (2018) attributed the increase in the number
of incidences of appendicitis to the poor diet and exposure to health hazards that are predisposing
to the condition.

While studying on the epidemiology of the appendicitis, Ceresoli et al. (2016) notes that it occurs
most often between the ages of 5 to 45 with the mean age at 28. The incurrences of appendicitis
stand at 233 per 100,000 people. Males are at a higher predisposition of developing appendicitis
in comparison to women with the lifetime incidence at 8.6% for men and 6.7% for women.
There is an approximate of 300, 000 hospital visits annually in the United States for appendicitis
related problems.
2.2 Symptoms and Diagnosis
Appendicitis presents typical symptoms and physicians from a wide range of specialties
including the internal medicine and pediatric such as surgeons, encounter patients suffering from
this condition. Nonetheless, in children and elderly the condition presents atypical symptoms,
which may not be easy to detect. The classical symptoms of the appendicitis include: dull pain
near the upper abdomens that at times becomes sharp as it moves to the lower right part of the
abdomen. The first signs of the appendicitis include loss of appetite, nausea, and vomiting at the
onset of the abdominal pain, abdominal swelling, lower fever, and inability of the pass gas. The
symptoms may change and appear by sharp pain anywhere the upper or lower abdomen, at the
back or in the rectum. The patient may also experience pain during urination, vomiting that
precedes the abdominal pain, severe cramps, and constipation with gas.
When a patient exhibits these symptoms, they are instructed not to eat, drink, use any
pain, remedies, and antacids, laxative or heating pads; these may cause the inflamed appendix to
rapture and fatality to occur. If these symptoms become exhibited on the patient, it is advisable to
seek a timely diagnosis and immediate medical attention. The pathophysiology of appendicitis
originates from the obstruction of the appendicieal orifices, which result in the inflammation and
perforation and the ultimate development of the contained abscess or frank perforation with a

resulting peritonitis. The obstruction may be caused by the lymphoid hyperplasia, bacterial or
parasitic infections, or malignant tumors. When the obstruction is considered to be the cause of
appendicitis, it may lead to an increase in the intraluminal or intramural pressure that results in
an occlusion of a small vessel as well as lymphatic stasis. Once the appendix is obstructed, it is
filled with pus and gets distended and with the lymphatic vascular compromise gets advances,
the wall of the appendix gets ischemic and necrotic.
The bacterial overgrowth subsequently occurs in the obstructed appendix and with
aerobic organism predominating in the early appendicitis does mixed aerobes and anaerobes;
infection occurs that may become fatal. Some of the common microorganisms that are common
in causing infections include Escherichia coli Escherichia coli, Peptostreptococcus, Bacteroides,
and Pseudomonas. One of the significant inflammations occurs; the appendix gets at risk of
perforation that may lead to a localized abscess and peritonitis. From the microscopic findings,
acute appendicitis may include proliferation of the neutrophils of the muscularris propia. The
extent of the inflammation is directly related to the severity of the infection and the duration of
the diseases. As the condition worsens, the extra appendiceal fat and the surrounding tissues get
involved in the inflammatory processes, which may require the resection at the time of surgery.
2.3 Evaluation
There is vast information relating to the evaluation of this condition. The emergency
department physicians ought to refrain from giving the patient any kind of medication until the
patient is seen by the surgeon. During the evaluation, the analgesics can mask the peritoneal
signs and may lead to delays in the diagnosis and even the rupture of the appendix. Kuma,
Kalyan, & Rehman (2017), note that lab testing is conducted to determine the condition the level
of response by the white blood cells. During the lab testing process, the WBC gets elevated with

or without the left shift in the bandemia, which is classically present up to one third of the
patients with acute appendicitis will be present with a normal range of the WBC count. In the
urine, there are usually ketones and the CRP may also be elevated with acute appendicitis.
The process of evaluation may take the form of imaging as explained by Kotagal et al.,
(2015) and Moore et al. (2016). During imaging, the appendicitis is diagnosed through a CT scan
that has about 95 % accuracy and is used with an increasing frequency. The criteria for the
appendicitis include enlarged appendix with a greater than 6 mm diameter, an appendiceal wall
thickening that has greater than 2 mm and fat stranding and a wall enhancement at the
appendiceal; this is common among 25% of the patients (Moore et al., 2016).
It is unusual to visualize the contrast in the lumen with the appendicitis due to the luminal
distention and a possible blockage in most of the reported appendicitis cases. Non visualization
of the appendix does not rule out the case of appendicitis. Ultrasound imaging is less sensitive in
diagnosis of the appendicitis compared to the CT but is also used when avoiding the ionizing
radiation in children as well as pregnant women. MRI may also be a useful method for the
pregnant patients with suspected appendicitis as well as indeterminate ultrasound (Moore et al.,
2016).
Di Saverio et al (2016) note that classically the best way for the diagnosis of the acute
appendicitis is to get a detailed history and physical examination as performed by a surgeon with
vast experience. Currently, it is easy to get a CT scan conducted in an emergency department and
due to the rapid results from the CT; it is currently relied upon in making diagnosis of the acute
appendicitis (Di Saverio et al., 2016). In some occasions, appendicoliths are found in the routine
x-rays or CT scans and patients get a higher risk of developing appendicitis than the general

population. These patients are considered for a prophylactic appendectomy and have shown a 10-
30% incidence in appendicoliths present in appendectomy specimens for acute appendicitis.
2.4 Treatment
When treating the patient for an emergency case, the patient must be kept under the NPO
and be hydrated intravenously with crystalloids. In line with the direction by the surgeon,
antibiotics may be administered depending on the purported infection due to the inflammation.
Indeed, the discretion of the drug administration depends on the consent from the surgeon.
As a gold standard for the treatment of the acute appendicitis, the surgeon should conduct an
appendectomy. Appendectomy can be open or laparoscopic depending on the decision of the
surgeon and the consent of the patient’s kin. Open appendectomy is considered a traditional
method and a standard treatment for the appendicitis condition. The surgeon makes an incision in
the lower abdomen, pulls the appendix through the incision that is made and removes it. On the
other hand, a Laparoscopic surgery encompasses the use of several smaller incisions with the use
of special surgical tools that is fed through the incision for the removal of the appendix.
Scholars and medical practitioners have varying views on the most preferable method of
surgical treatment. For instance, Jaschinski et al. (2018) argues that laparoscopic surgery has
lesser complications than the open appendectomy as characterized by lesser infections and
shorter recovery time. Nonetheless, some scholars such as Beg et al. (2017) notes that
laparoscopic appendectomy is more preferred over the open approach. Jaschinski et al. (2018),
state that most of the uncomplicated appendectomies are conducted in a laparoscopic manner.
From the scholarly work, there is no consensus on the most appropriate method and hence the
need for a study that uses the current researches and practice to provide knowledge to the
practitioners, which of the two surgical operation methods is more advantageous.

2.5 Open Appendectomy and Laparoscopic Appendectomy
Scholars and health practitioners have attempted to determine which of the two methods
are appropriate and at which situations. According to Horvath et al. (2017), in instances where
there is an abscess or an infection, an open approach is needed. Nonetheless, the laparoscopic
approach is less painful, leads to better recovery and there is ability of exploring the abdomen
through small incisions. In situations where there is a known abscess from an appendix that is
perforated, it may require a percutaneous drainage procedure that is usually done through an
interventional radiologist. This approach stabilizes the patient and allows for an inflammation to
subside over time thereby enabling a less difficult laparoscopic appendectomy to be conducted at
a later day. Health practitioners also start with the provision of a broad spectrum antibiotics but
there is a disagreement regarding the preoperative antibiotic to be administered for the
appendicitis that has no complications. Some surgeons prefer the administration of the routine
antibiotics while others feel that this is not warranted. There are other studies that promote the
treatment of the appendectomy with the sole use of antibiotics for the uncomplicated appendicitis
thereby avoiding surgical treatment.
In patients with the appendiceal abscesses, some surgeons continue to use the antibiotics
for a few weeks and then an elective appendectomy is conducted. When the appendix ruptures,
the procedure can be conducted using a laparoscopic method but extensive irrigation of the
abdomen and pelvis are essential. Salminen et al. (2015) state that appendectomy can be done
either through laparoscopic or open surgery techniques depending on the level of patient’s
complications. However, Salminen et al. (2015) advocates for a laparoscopic surgery method
noting that it is associated with reduced postoperative pain, shorter length of the hospital and a

subsequent faster return to the daily activities. This method is merited with the reduced poster
operative illumes and better cosmetic results compared to an open surgical method whose
incision leads to a larger body scar that takes longer to heal. Within the last five decade, the
mortality of the acute appendicitis has declined rapidly, a move that is associated with the ability
of conducting faster surgical operations. Despite the increased popularity for the laparoscopic
surgical operation, there is still high number of cases that are treated through open surgical
appendectomy. In a study that was conducted in the year 2016 revealed that surgical operation
was applied in more than 4000 patients and 45% of the cases were treated using this open
appendectomy method. This is common with the uncomplicated appendicitis, but the more
complicated cases are well managed using the laparoscopic surgery method. It is essential to note
that surgical operations for this treatment just like any other are prone to complications such as
persistent ileus, fistula, pelvic abscesses, and surgical site infections. As such, in making the
decisions of the most suitable method between open and laparoscopic surgery method, it is
essential to take note of the healthcare complications and the nature of the patient.
Scholars have different views in regard to the choice of the appendectomy for the
complicated appendicitis. According to Nikolić-Micković et al. (2016) LA has an advantage over
OA when dealing with the complicated appendicitis. Nikolić-Micković et al. (2016) state that the
LA leads to lesser intraoperative and postoperative complications and hence a remedy when
dealing with children who have complicated appendicitis. The same assertion are shared by
Karakuş et al. (2016) who argue that single port LA is better than OA for the complicated
appendicitis. This is justified by the argument that LA is associated with shorter recovery period
after operation, it reduces the postoperative wound infection, and does not cause an increase the
operative cost. Boo, Lee & Lee (2016) also agreed to this assertion stating that Laparoscopic

surgery was considered the best appendectomy method for treatment of complicated appendicitis
on young children as it leads to lesser complications with the data showing a 63% complications
for the OA against 26% for the LA. Other scholars who attested to the suitability of LA for
complicated appendicitis include Schnauzer et al. (2018); Mendoza-Sagaon et al. (2016); and Li
et al. (2018). Nonetheless, some scholars believe that OA is more suitable for the complicated
appendicitis or refuted assertions that OA leads to better outcome. Concerning this, Taguchi et
al. (2016) conducted a randomised controlled trial study asserted that encompassed 81 patients
were included in the study and assigned on a 1:1 allocation ratio of LA and OA (42, LA; 39,
OA). From the study, it emerged that the suitability of OA for complicated appendicitis could not
be justified. This position was also stated by Beg, Faridi, Qazi & Siddiqui (2017) and Johnson,
Linnaus & Notrica (2018). As such, there is need to justify in a more reliable manner, the choice
of the surgical operation for the complicated appendicitis on children between OA and LA. 
From the review of the previous studies, there is no clear consensus on the most
appropriate choice based on modern literature. In line with this, the proposed study seeks to use
the modern based literature from peer reviewed scholarly journals to review the most preferred
method based on several aspects. The study will review on the following aspects: duration of
operations; rate of infection; safety and efficacy; application on obese patients; application on
pregnant mothers; application on children; operation costs; ease of return to work; and cosmetic
outcome among others. The findings will bridge the knowledge gap and offer valuable
information to practitioners in healthcare.

Chapter 3: Methodology

3.1 Data Collection and Sampling

This research is based on systematic review of literature. The systematic review of the
literature encompasses the identification of the journals that relate to the appendectomy, critical
evaluation, and subsequent synthesis of the data from medical academic sources. Data was
collected from scholarly journals that explain the differences between the two types of
appendectomy OA and LA in a bid to provide answers to the research questions. The data was
collected from peer reviewed scholarly journals. The process of the literature review started with
the rigorous and protocol driven review of academic and medical sources that explain the process
of open and laparoscopic appendectomy to discern the difference as well as help in defining the
most appropriate method between the OP and LP. The sources were derived from the medical
based academic journal databases.
The following were chosen as the database for the academic information relating to open
and laparoscopic appendectomy:
PubMed: This is a free search engine that gives access to the Medline databases references,
abstracts, and full text journals along the biomedical topics. The database is maintained by the
United States National Library of medicine at the National Institutes of Health.
CINAHIL: this is an English based database with journal articles on nursing, allied health,
biomedicine, surgery and healthcare. The journal articles provided information relating to OP
and LP hence answer the research questions.
EMBASE: this is a biomedical, pharmacological, and bibliographical database that is published
literature that is designed to provide supporting information on treatments and medical remedies.
Cochrane Library: this is a collection of database relating to medicine and other healthcare
specialties that relate to health. The database is known for its systematic review and meta-
analyses that summarize and interpret the results of medical research.

Science Direct: this is a large database constituted of scientific and medical research journals. It
has over 12 million pieces of content derived from over 35000 journals and e- books.
Google scholar: this is a search engine with millions of journals, conference papers, and e-books
across many disciplines. The database has filter attributes for the selection of the recent and
relevant information relating to the issue of study.
3.1. 1 Sampling
The researcher applied a purposeful sampling technique to collect data from the specific
journals that dealt with the topic of appendectomy. The researcher applied a transparent and
rigorous approach in the search of the appropriate literature, selected publication to be included
in line with the purposeful and iterative process as explained by Gentles et al. (2016). This
approach requires a multistep approach including abstraction of text, review of the summary
information to ensure that the selected sources have the necessary information regarding the
difference between open appendectomy and laparoscopic appendectomy.
In the sampling process, three major strategies were applied to sample the appropriate sources:
Strategy #1: In limiting the set of publications that ought to included and exclude some sources,
the reviews selected the medical and health databases from which to find the data. In this case,
the selected databases contained information related to health. The use of key words was
essential in selecting the most important journal articles.
Strategy #2: The search criteria were further refined because in the first search, the researcher
retrieved huge volumes of sources some of which never met the objective of the study.
Strategy #3: this encompassed the identification of the relevant publications for inclusion.

Strategy #4: in identifying the useful books and journals that may contain relevant information
for inclusion and the exclusion of some, the process may include the review of the content. After

choosing the sources with the topic that relate to either OP or LP, the researcher reviewed the full
text to determine whether the selected sources should be included or not in line with the
purposeful sampling technique.

The exclusion and inclusion criteria is summarised below:

Criteria Inclusion Exclusion
Time period January 2015– May 2018 Before 2015
Language English Other languages
Setting Studies with Children Studies with no children and
does not deal with OP and LP.

Type of studies Primary and secondary

studies

Reports, unpublished journals,
commentaries, and letters.

Aim: To compare open
appendectomy and laparoscopic
appendectomy

Literature that compares the
two surgical operations: OP
and LP

Literature that does not compare
between OP and LP

3.1.2 Critical Appraisal using CASP
In appraising the sources that were used in the systematic literature review, CASP tool
was used as the method of appraisal. The Critical Appraisal Skills Program (CASP) is a research
tool that helps in developing an evidence based approach for health and social care. This
approach finds its way in research as it helps to make sense of a study through research evidence
that helps them to make conclusion on healthcare. The CASP under the systematic review
encompassed of ten questions that were designed to assess the sources systematically. In the
analysis, the first two questions are considered as screening questions that prompts to find the

suitability of the source under review. The study encompassed of 25 sources that were sampled
from the five databases that were explained earlier, and they were reviewed under the CASP
checklist to determine their suitability for inclusion or exclusion. The CASP is the appropriate
method of appraisal for sources as it helps in systematic review of literature by ensuring that the
selected sources not relevant and meet the quality parameters.
Key interventions in the CASP is to review the sources selected one by one to ensure that
they meet the criterions stated in the checklist as attached in appendix. Apart from reviewing the
sources in line with the CAP requirements, the practical appraisal was conducted to make the
decision for inclusion and exclusion. In doing this, process of appraising was to eliminate the
sources that were not relevant as well as those of poor quality and not able to answer the research
questions/ hypothesis.
Research Effect
To ensure reliability, validity, and trustworthiness, the researcher appraised the sources, a
process that was conducted meticulously while guided by the CASP tool to ensure that relevant
high quality sources were not discarded. This was done by:
 The content of the source and the variables in regard to the research question: the reviewer
assessed the responses to see if the research question was in agreement with the CASP
requirements on suitability.
 Language of publication: the source was reviewed in respect of the language to ensure that it
demonstrated proper use of medical and scholarly language.
 Journals: the specific journals that were included in the literature ought to be from reputable
publishers and from the medical field and divulge on the appendicitis condition and
appendectomy.

 Authors: the review also sought to find if specific reputable authors who have explored and
made a comparison of the OP and LP were included in the list. On this note, some of the key
authors in this case include Beg et al. (2017); Jaschinski et al. (2015), and Biondi et al.
(2016).
 Research Settings: the study herewith is based on the comparison of two surgical treatment
methods for the appendicitis (open appendectomy and laparoscopic appendectomy).
Therefore, key aspect in reviewing the articles that were used in making decisions regarding
the most appropriate one for children is the research setting. The studies that were not
conducted on medical research settings were excluded in the study as they had no
professional command.
 Participants: some of the sources were rejected since the participants were not children and
hence the findings could not be extrapolated to such.
 Research design and method of sampling techniques: some of the sources were excluded due
to the poor research design and wrong sampling approach.
 Date of publication: the study excluded the sources that were older than five years.
Publication Type
The researcher relied on the peer reviewed journals, published reports, and conference papers. In
this case, the researcher excluded non-published sources
3.2 Ethics
To minimize bias, the researcher was guided by the CASP checklist that enabled to make
choice of the only appropriate sources while also excluding the non-standard sources. In
addition, in an attempt to prevent misrepresenting the results, the data was tabulated directly
from the source. In this case, whether the source promoted open or laparoscopic appendectomy,

the findings were tabulated on a one on one basis without alteration. The table was cross checked
severally to avoid misrepresentation and bias. Plagiarism was avoided by crediting the specific
authors. In this case, the narratives were formulated from the tables and after paraphrasing the
content, the specific authors were acknowledged in line with the APA citation standards. This
was aided by the use automatic citation tool “Endnote.” Subsequently, an accurate reference list
was developed with the help of the automatic citation tool Endnote.
3.3 Data Extraction Method
Decision of what to include and not to include should be guided by the review question
After the sources were tabulated well, the information was systematically derived and tabulated
to serve as the source for the synthesis of the data. The information was tabulated with the major
focus being on the choice of the open or laparoscopic appendectomy. At the extraction stage, the
data was not detailed but rather picked in line with the specific objectives. The data was
collected in a form with the choice between the OP and LP, the justification, the research
settings, the population, sample size, and the study design. The extracted data was used for the
subsequent data synthesis where narration was included with comprehensive explanation.
Data to be extracted include not only the outcomes but also the methods used to obtain the
outcomes, and the validity and reliability of those methods.
3.4 Data Synthesis
In the data synthesis stage, the researcher created data based on the themes that were
recurrent. In this case, the widely chosen surgical treatment method of appendicitis was noted
with the explanation and justification in narrative form. In this case, the researcher used a
narrative synthesis to create a report of the findings. The narrative encompassed an explanation
and justification of the surgical appendectomy method of choice with the clear focus being on

the research objective. Indeed, the narrative explained the theme in narrative form while
justifying with the literature. The researcher explored the patterns, the variations in the findings
from the various studies. The synthesis encompassed a slight manipulation of statistical data but
these were explained through textual content that told the story on the findings. The researcher
also included the populations, the heterogeneity of the findings, and the study designs.

Chapter 4: Results and Findings

The aim of this study is to compare the two types of surgery, Open appendectomy and
laparoscopic appendectomy, to find out which is best for children with appendicitis, and hence
improve nurses ‘ knowledge of the two types of surgery to help them improve their care. In light
of this the results and findings seeks to provide the answers to the following research questions:
I. What is the difference between open appendectomy and open laparoscopic appendectomy as
surgical treatment for appendicitis?
II. Following the concept of patient-centered care, which of the two approaches is more
concerned with the patients?
III. Which of the two approaches open appendectomy and open laparoscopic appendectomy are
most appropriate for children as a treatment method of surgical treatment for appendicitis?

References

Becker, P., Fichtner-Feigl, S., & Schilling, D. (2018). Clinical Management of
Appendicitis. Visceral medicine, 34(6), 453-458

Beg, M. A., Faridi, S., Qazi, A. R., & Siddiqui, F. (2017). Laparoscopic appendectomy-
comparison with open appendectomy with respect to surgical site infection. Pak J
Surg, 33(2), 115-118.
Ceresoli, M., Zucchi, A., Allievi, N., Harbi, A., Pisano, M., Montori, G., … & Coccolini, F.
(2016). Acute appendicitis: Epidemiology, treatment and outcomes-analysis of 16544
consecutive cases. World journal of gastrointestinal surgery, 8(10), 693.
Childers, C. P., Dworsky, J. Q., Massoumi, R. L., Shenoy, R., Maggard-Gibbons, M., Lee, S. L.,
& Russell, M. M. (2019). The contemporary appendectomy for acute uncomplicated
appendicitis in children. Surgery, 165(5), 1027-1034.
Danwang, C., Mazou, T. N., Tochie, J. N., Nzalie, R. N. T., & Bigna, J. J. (2018). Global
prevalence and incidence of surgical site infections after appendectomy: a systematic
review and meta-analysis protocol. BMJ open, 8(8), e020101.
Di Saverio, S., Birindelli, A., Kelly, M. D., Catena, F., Weber, D. G., Sartelli, M., … & Agresta,
F. (2016). WSES Jerusalem guidelines for diagnosis and treatment of acute
appendicitis. World Journal of Emergency Surgery, 11(1), 34.
Ferris, M., Quan, S., Kaplan, B. S., Molodecky, N., Ball, C. G., Chernoff, G. W., … & Kaplan,
G. G. (2017). The global incidence of appendicitis: a systematic review of population-
based studies. Annals of surgery, 266(2), 237-241.
Ferris, M., Quan, S., Kaplan, B. S., Molodecky, N., Ball, C. G., Chernoff, G. W., … & Kaplan,
G. G. (2017). The global incidence of appendicitis: a systematic review of population-
based studies. Annals of surgery, 266(2), 237-241.
Glass, C. C., & Rangel, S. J. (2016, August). Overview and diagnosis of acute appendicitis in
children. In Seminars in pediatric surgery (Vol. 25, No. 4, pp. 198-203). WB Saunders.

Horvath, P., Lange, J., Bachmann, R., Struller, F., Königsrainer, A., & Zdichavsky, M. (2017).
Comparison of clinical outcome of laparoscopic versus open appendectomy for
complicated appendicitis. Surgical endoscopy, 31(1), 199-205.
Jaschinski, T., Mosch, C. G., Eikermann, M., Neugebauer, E. A., & Sauerland, S. (2018).
Laparoscopic versus open surgery for suspected appendicitis. Cochrane Database of
Systematic Reviews, (11).
Jaschinski, T., Mosch, C., Eikermann, M., & Neugebauer, E. A. (2015). Laparoscopic versus
open appendectomy in patients with suspected appendicitis: a systematic review of meta-
analyses of randomised controlled trials. BMC gastroenterology, 15(1), 48
Khan, M. N., Rafique, S., & Ranaboldo, C. J. (2009). Laparoscopic management of heterotopic
pregnancy—a rare cause of acute abdomen in women. Surgical Laparoscopy Endoscopy
& Percutaneous Techniques, 19(1), e29-e31.
Kotagal, M., Richards, M. K., Flum, D. R., Acierno, S. P., Weinsheimer, R. L., & Goldin, A. B.
(2015). Use and accuracy of diagnostic imaging in the evaluation of pediatric
appendicitis. Journal of pediatric surgery, 50(4), 642-646
Kumar, B. A., Kalyan, K. A., & Rehman, M. M. (2017). Perforation in acute appendicitis:
evaluation of hyperbilirubinemia and elevated C reactive protein as a predictive
factor. IAIM, 4, 18-23.
Low, Z. X., Bonney, G. K., So, J. B. Y., Loh, D. L., & Ng, J. J. (2019). Laparoscopic versus
open appendectomy in pediatric patients with complicated appendicitis: a meta-
analysis. Surgical endoscopy, 1-12.

Moore, M. M., Kulaylat, A. N., Hollenbeak, C. S., Engbrecht, B. W., Dillman, J. R., &
Methratta, S. T. (2016). Magnetic resonance imaging in pediatric appendicitis: a
systematic review. Pediatric radiology, 46(6), 928-939.
Reddan, T., Corness, J., Mengersen, K., & Harden, F. (2016). Ultrasound of paediatric
appendicitis and its secondary sonographic signs: providing a more meaningful
finding. Journal of medical radiation sciences, 63(1), 59-66
Reitz, K. M., & Zuckerbraun, B. S. (2019). Treating the Patient With Appendicitis, Not Just the
Appendicitis. JAMA surgery, 154(2), 149-149.
Salminen, P., Paajanen, H., Rautio, T., Nordström, P., Aarnio, M., Rantanen, T., … & Sand, J.
(2015). Antibiotic therapy vs appendectomy for treatment of uncomplicated acute
appendicitis: the APPAC randomized clinical trial. Jama, 313(23), 2340-2348.
Switzer, N. J., Gill, R. S., & Karmali, S. (2012). The evolution of the appendectomy: from open
to laparoscopic to single incision. Scientifica, 2012.
White, E. J., McMahon, M., Walsh, M. T., Coffey, J. C., & O’Sullivan, L. W. (2019). A study of
laparoscopic instrument use during colorectal surgery. Applied ergonomics, 78, 301-308.

Appendices

Appendix A: CASP